Mental disorders in epilepsy

the locomotor component, classical absences. Subsequently predominate the versions with the postural and psycho-motor components, the massive vaso-vegetative dissociations, and also the generalized convulsive with the expressed phenomena of postparoxysmal nervous exhaustion.

On the course of disease appear continuouns periods of the decompensation, whose heaviest manifestations should be considered frequent series of convulsive seizures, status-like states and statuses, dreamy obscurings of consciousness, constant obnubilation and finally the increase of the signs of epileptic dementia, to the foreground in structure of which come out brutal explosiveness, insolvency in the estimation of the surrounding events, torpidity, viscosity of thinking and mnestic disturbances.

An increase in the daily doses of anti-consultants to the maximally recommended level is a frequent method for stopping the paroxysmal syndrome. This tactics is dictated by the high resistance of paroxysms. Psychotic disorders seemingly continue the processual motion of disease, to a considerable extent growing from the personal pathology. The steadfast loss of the professional ability to work of patients is explained by the appearance of polymorphous psychotic disorders, which testify to the deep disorder of cerebral functions. The combination of psychosis with a gross mnestico-intellectual decrease is noted here most frequently. As a result of the fact that the structure of dementia is characterized by special complexity, it is sometimes difficult to outline any sequence in the development of psychosis. Only in the more remote stages of the epileptic process comes a certain stabilization of the clinical picture of the disease, it is possible the social and labor rehabilitation.

The psychoses with the catatonic disorders most frequently are noted among the transitory psychotic states. To the paroxismal psychoses they relate the different duration of the disorder of catatonodelusional and catatonic register. Chronic psychoses are predominantly querulant delusions in combination with the manifestations of secondary catatonia or catatonic states with the affective-delusio- nal inclusions.

In addressing the medical and social and psychiatric examination should be guided by the fact that a regression of paroxysmal syndrome leading diagnostic criteria weighting, along with the dynamics of personality disorders are the structure and variability of the transitional nature of positive symptoms.

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In the plan of psychiatric diagnosis practically expedient is the isolation in the development of psychopathological disorders with epilepsy of four stages. In the first clinical mental functions remain unchanged. Starting from the second level is detected in the growing pattern of epileptic dementia. In the second stage there is a decrease of creative features, memory, having expressed affective disorders. In the third stage the obvious factor is clinical inertia, stiffness and subject-specific nature of thinking. The fourth phase is “concentric dementia.”

The evidence that the variants of the course and the stage of disease are major determinants of the diagnosis is the dependence of the nature of disease outcomes not only on those specific to each individual case of some form of flow psychosis: transient, schubweise or chronic, but on the register of psychotic disorders: affective, delusional or catatonic.

During the first stage the development of psychopathological disorders, i.e., before the appearance of signs of dementia, the ability to work remains with the transitory depressions with hypodynamia and sensitive delusion of relation, the sub-depressive paroxisms of psychosis, chronic affective-delusional disorders with the supervaluable ideas. Temporary disablement begins with an increase in the structure of the transitory psychoses of the portion of vegetative and delusional components, the appearance in the structure of the schubweise psychoses of the ideas of low value, hypochondriac reactions, aggravation of the delusional experiences within the framework of chronic affective-delusional psychosis. Patients restrictedly are able-bodied or completely disabled with the protracted affectivedelusional schubs of psychosis, the loading of the clinical picture of disease due to the catatono-delusional, catatonic or polymorphous psychotic disorders.

At the second stage of the development of psychopathological disorders, which is manifested by the predominance in the structure of dementia of affective disturbances, the ability to work of patients with the paroxismal psychoses of predominantly delusional structure stably is reduced as a result of significant reduction in the ability to adequately evaluate production situation, tendency toward the conflicts. Patients are disabled with the domination in the structure of the chronic psychosis of hallucinatory-delusional and catatono-de- lusional disorders.

At the third stage of the development of psychopathological disorders, which is characterized by steadfast and expressed disturban-

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ces of thinking, by bradyphrenia, appears the possibility of wider job placement of patients in the specially created conditions during the stabilization of the structure of polymorphous psychotic formations. Patients are disabled in the cases of the development of paranoid epileptic dementia.

At the fourth stage of the development of psychopathological disorders is formed the expressed mnestico-intellectual defect. With the decrease of the portion of affective and delusional disorders the patients, who were being recognized as disabled at the previous stages of disease, can be fitted out to the labor in the therapeutic-working workshops or the special shop or under the conditions of usual production. The patients are disabled with the predominance in the structure of the polymorphous protracted and chronic psychotic states of sub-stuporous manifestations.

Timely use of these criteria for the diagnosis of multiple versions of the structure and dynamics of epileptic psychosis and dementia, together constitute an extensive, but until now still insufficiently studied, area of pathology, will facilitate the identification and use of a rehabilitation plan of residual disability or proper evaluation and prevention of socially dangerous action on the part of one of the most common troops of mentally sick.

The predominance of neurologic approach to diagnostics of epilepsy nowadays, reflected in ICD-10, apparently, is the consequence of the disagreement of the actions of experts neurologists participating in the creation of the classification and psychiatrists. The first, as we know, are engaged in research and treatment of predominantly early stages of the disease, the second – more remote. With the appearance of mental disorders in patients the neurologists willingly part from their patients, and even most radically inclined of the doctors, who refer to the treatment of epilepsy, neurosurgeons – in majority consider mental disorders with this disease by contra-evidence not only for the surgical intervention, but also for neurologists. (R. Marchanda et al.,1993; D. Blumer et al.,1998; P. Shaw et al.,2004).

By indisputable indication for the successful early surgical intervention W.J. Kim et al. (1997), Y. Mayanagi et al. (1997) counted mesiotemporal sclerosis with the resistant to the medicinal therapy by epilepsy. At the same time, Р. Могаn et al. (1997) cite data, from which the patients, directed for the operation apropos of resistance temporal epilepsy, frequently reveal during the structured psychiat-

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ric estimation diverse mental disorders. P.E. Selai et al. (1997) assume that only 20% of patients with epilepsy, directed in the neurosurgical department, do not have psychological and psychiatric contra-evidence for the operation.

According to the evidence of E. Garcia-Flores (1997), long-term results of the surgical treatment of epilepsy rarely are described in the medical literature. The author reports his own results conducted from 1972 to 1994. by retrospective study of 100 adult patients who had an average of 13.2 years ago surgical operation for refractory complex partial seizures. According to the author, completely freed from the seizures and completely self-reliant were 32% of patients. Noted benefit from the operation, but “were not satisfied by themselves” were 28% of patients, but 25% of patients had by result of operation surgical and psychological failures. Based on the fact that mental disorders prior to surgery had 15% of patients and 6% of them during the follow-up attempt suicide, the author comes to a conclusion about the need to recognize chronic mental disorder contraindication to surgery for epilepsy. Psychiatrists, as a rule, do not locate or disregard data of the previous inspection and treatment of patients in neurologists and do not connect the nature of the initial stages of disease, but at the same time also the neurologic classification of epilepsy with the observing picture of mental disorders. As a result in the practice of conducting the patients with epilepsy the majority of neurologists, actually, doesn’t know distant (lasting) catamnesis of almost all forms or versions of epilepsy, which are brought in ICD-10 under the heading of G40. S. Macrodimitris et al. (2011).indicate to the need for conducting the controlled studies of prevalence and gravity of mental disorders after the surgical treatment of epilepsy and identification of their predictors.

Only some of the neurologists predict for a short period in their patients some degree of developing a mental disorder.

On the basis of the results of the conducted investigations G. Bogliun et al. (1997) consider that patients with cryptogenic or idiopathic epilepsy have no greater risk of onset of psychiatric disorders than the population, not controlled neurologically. Favorable prognosis with the relative safety of intellect with epilepsy in patients with children’s cerebral paralysis was noted by K.L. Kwong et al. (1997). At the same time in patients, who enter the treatment the children’s neurologic ambulatory, P.M. Leary et al. (1997)

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in the substantial part of the cases noted the expressed “disorder of mental development”. In the opinion of R. Lossius et al. (1997), adolescents with epilepsy have the increased risk of the appearance in them of mental disorders. The high frequency of mental retardation in patients with the series seizures with West Syndrome and Lennox-Gastaut Syndrome was noted by M. Yoshida et al. (1997).

Neurologists often express to the psychiatrists largely justified accusations that they don’t spend enough research to understand the pathogenesis and, therefore, the development of pathogenic treatment of paroxysmal disorders in epilepsy. In response to this the second are amazed with the tunnel vision of the first only formally binding, in their view, mental disorders with epilepsy, considering them not logical manifestation of the disease, but only a consequence of its resistance to the therapy, or the result of improper treatment.

The appearance of a similar kind of unproductive discussions between the doctors of different specialties, occupied with the treatment of epilepsy, and also the significant heterogeneity of views on the origin with it of mental disorders can be confirmed by the following examples.

By reason of “psychotic demonstrations” in epilepsy Sh. Bibileishvili (1997) counts “an increase in the level of drug-induced intoxication”. Doubting in the fact that the beginning of epilepsy at the childhood always leads to the personal disorders in the period of growing of patients, D. Fitzpatrick et al. (1997) in the basis of the conducted by them analysis place only the fact of the appearance of epileptic seizure in children, without giving others data, who have, as it is testified the results of our studies, value for the prognosis: the types of seizures, the frequency of their repetitions, polymorphism, the effectiveness of antiepileptic therapy and other. L. Forsgren (1997) by the “most studied prognostic sign” considers the remission of seizures. “The levels of psychopathology” S. Jarvie et al. (1997) relate with “social and physical influences of epilepsy”. Reason “for increase the risk of the appearance of mental disorders” in adolescents with epilepsy R. Lossius et al. (1997) see only in the fact that they are “imposed restrictions and limitations in everyday life.”

If to compare the diagnosis of epilepsy, as contained in section G40. – ICD-10, with proposed by us classification of types of course

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of the disease, then based on data from the above and previous chapters it is possible to draw following most common assumptions, that need to be scrutinized in special clinical follow-up studies (Table 1).

The favorable type of the course of disease apparently, includes myoclonic epilepsy of early childhood and neonatal spasms.

Localized epilepsies with the simple and complex partial seizures supposedly can be referred to the type of the course of disease with the set aside exacerbation.

The unfavorable type of the course of disease includes generalized epilepsies with the syndrome of Lennox-Gastaut, “salaam” ticks, early myoclonic encephalopathy, West’s syndrome .

Particular is need for the clarification of type of disease, in children epileptic absence seizures (piknolepsiya), epilepsy with generalized seizures on awakening, juvenile epilepsy, epilepsy with myoclonic absences, myoclonus-astatic seizures and Infantile spasms.

The need for conducting the corresponding studies in the certain degree is confirmed by a number of epidemiological data, given in the literature of last time.

First of all, it is necessary to note that according to the data of the epidemiological study, carried out by P. Satischandra et al. (1997), primarily generalized tonic-clonic epilepsy composes in the general population of the patients with epilepsy 54,5%, partial epilepsy – 27,4%, reflector epilepsy – 6,9%, myoklonusepilepsy – 1,9%, pseudoseizures – 1%, absences – 0,3%. According to the data of the epidemiological study, carried out in Columbia by A. Velez et al. (1997), the population of the patients with epilepsy in majority its is the cases of symptomatic partial epilepsy.

According to the data of H. Quattrini et al. (1997), based on the study of 2152 out-patient-children and adults, partial seizures occur in 84% of cases of epilepsy (only simple partial seizures – in 3% of cases, only complex partial seizures – in 16,4% of cases, with the second generalization – in 64,6% of cases). However, primarily generalized (convulsive and convulsiveless) seizures, according to the data of the authors, are observed in 13,2% of cases, and syndrome of LennoxGastaut – only in 2,8% of cases.

According to F. Semah et al. (1997), the accomplished continuous study of 2075 out-patients with epilepsy older than 16 years, epilepsy with the established localization is diagnosed in 60% of cases, in 21% of cases – generalized epilepsy, in 17% of cases – epilepsy with the unestablished localization.

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Given data confirm the conclusion of F. Semah et al. (1997) about the fact that the contemporary international classification of epilepsy gives the possibility to outline a study only of some facts, which lie at the basis of prognosis.

As for the literature data, directly relating to a question about the combination of neurologic and mental disorders in that order of designations, which is used in the heading G40 ICD-10, it is possible to establish only a few which can be accepted as the criteria of the type of the course of disease.

Children benign partial epilepsy (G40.0) is characterized by P. Vigliano et al. (1997) as the absence of cognitive impairment, but, as the authors note, patients show emotional problems, while 75% of them say psychosomatic disorders.

Table 1

Criteria of the diagnosis of epilepsy on ICD-10 and possibility of establishing the type

of the course of the disease

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In 35% of inspected children with favorable focal epilepsy (G40.0) H. Mayer et al. (1997) were revealed the disorders of attention and emotional disorders.

In children with symptomatic partial epilepsy (G40.1 and G40.2), Z. Martinovic et al. (1997) and A. Pelliccia et al. (1997) note the disorders of attention.

Cognitive defeciency in children, according to H. Holthausen (1997), more frequently occurs with symptomatic (G40.1 and G40.2) epilepsy, than with the idiopathic. In the majority of patients with the simple or complex partial seizures with presence or absence of secondary generalization (G40.1 and G40.2) in the presence of experience auras in patients, R. Manchanda et al. (1997) frequently revealed mental disorders. Adolescents, who were observed by T. Wolanczyk (1997) with the complex partial seizures (G40.2), were characterized by the distinctly decreased level of optimism and by the lowered self-apprai- sal. According to E.J. Clarke et al. (1997), in all cases with the complex partial seizures (G40.2) occurred “non-affective psychoses”. In patients with the complex partial seizures (G40.2) B.H. Landgrebe (1997) observed alternative shizophrenia-like psychoses with the decrease of the frequency of seizures and the forced normalization of EEG.

E. Sarac et al. (1997) based on the results of their study argued that most of the tests used to detect memory, show it’s damage not only in partial (G40.1 and G40.2), but also in primary generalized (G40.3) epilepsy.

With “surface screening” of mental disorders G. Bogliun et al. (1992) revealed the predominance of depressions in patients with idiopathic epilepsy (G40.0 and G40.3).

High-quality neonatal (family) siazures (G40.3), according to of F. Vigevano et al. (1997), have favorable outcome in the plan of psy- cho-motor development in patients. On the small number of cases N. Tatishvili et al. (1997) cite the data about untreated juvenile myoclonic epilepsy (G40. 3) and grand mal with the awakening (G40.3) and also report that in patients at the age from 50 to 75 years with the diagnoses indicated and by the preservable rare seizures are noted the normal intellect and correct behavior. With juvenile myoclonic epilepsy (G40.3) V. Sofia et al. (1997) note the disorders of short term memory and calculation. With juvenile myoclonic epilepsy, entering as the syndrome the group of idiopathic generalized epilepsy (G40.3) S. Malagold et al. (1997) revealed in patients the cognitive insufficiency, which, as they think, can explain variation in social behavior in patients.

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According to W.M. Burnham (2002), up to 20% of patients with idiopathic familial epilepsy are resistant to the conducted drug therapy, and third of them have mental disorders.

By medical factor, which refers to the delay of the investigating behavior and social experience in the preschool kids, O. Sugiyama et al. (1997) counted generalized epilepsy of any origin (G40.4). An increase in the connection between the behavioral and cognitive disorders in children was established by Z. Martinovic et al. (1997) with the syndrome of Lennox-Gastaut (G40.4). With the West’s syndrome (G40.4) 85-90% of cases of the disease F. Vigevano et al. (1997) carry to symptomatic epilepsy, and patients, according to their data, reveal “progressive psycho-motor decrease”.

These data indicate undirected, random nature of the research in the field of mental disorders under the “major epileptic syndromes” that have been adopted by the Commission on Classification and Terminology of the International Epilepsy League Against Epilepsy, and that came in the ICD-10.

The only possible permission of the contradictions between three groups of specialists – neurologists, neurosurgeons and psychiatrists created – is, in our opinion, the association of their efforts for the formation of integral approach to conducting of patient for the early stages of disease. The world and domestic practice of the organization of antiepileptic service already manufactured this form as the activity of the centers of epilepsy.

Antiepileptic specialized centers operate in a regular patient visits to the clinic and regular medical effects on their status (J. Beaussart-Defaye et al., 1997) and in many cases offset the deficiencies in this regard of health services in general (N.E. Bharucha et al., 1997; M. Boyle, 1997; V. Brulde, 1997; N. Collinge, 1997; F. Semah et al., 1997). The data base about different contingents of the patients is created by them: children with the established epileptic syndromes (A. Berger et al., 1997; P. Jallon, 1997), patients, included in the protocol of conducting diagnostics and of treating epilepsy and other technologies (E. Centurion et al., 1997; S.J. Currie et al., 1997; V. Dalla Bernardina, 1997), patients with the presence of indications and contra-evidence for the surgical treatment (E. Garcia-Flores, 1997; S. Jarvie et al., 1997; K. Larsson et al., 1997).

Another practical problem is the testing centers and the implementation of case management multidisciplinary team of specialists, which in some cases includes nurses, social workers, physiothera-

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